RESUMEN
We sought to validate a previously described clinical prediction rule for classifying left ventricular ejection fraction (LVEF) after acute myocardial infarction (AMI). As part of the Connecticut cohort of the Cooperative Cardiovascular Project (CCP) pilot study, we identified 3,093 Medicare patients who had been admitted to hospitals throughout Connecticut with an AMI in 1992 and 1993. Retrospective chart review and detailed electrocardiogram interpretation were performed. Of the 1,891 patients with an interpretable EF, 1,378 (73%) had > or = 1 of the rule's exclusion criteria. Of the remaining 513 patients, the clinical prediction rule had a positive predictive value of 89% (i.e., 456 of 513 patients had an EF > or = 40%). In a multivariate model, presentation > 6 hours after the onset of chest pain, a history of bypass surgery, and diabetes mellitus were associated with patients in whom the rule did not correctly predict an EF > or = 40%. Excluding patients with these characteristics from the rule increased the positive predictive value from 89% to 93% and excluded an additional 239 patients. The EF could not be predicted among the patients who did not meet the rule's criteria. In conclusion, a previously published clinical prediction rule for the classification of the EF in patients after an AMI correctly classified 8 of every 9 eligible elderly patients as having an EF > or = 40%. Thus, while not performing as well as it did in the original study, our findings support the use of this rule in providing clinicians with an objective method for estimating an EF > or = 40% in a specific subset of elderly patients.
Asunto(s)
Infarto del Miocardio/clasificación , Infarto del Miocardio/fisiopatología , Volumen Sistólico/fisiología , Función Ventricular Izquierda/fisiología , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Connecticut , Ecocardiografía , Electrocardiografía , Femenino , Humanos , Masculino , Medicare/estadística & datos numéricos , Análisis Multivariante , Proyectos Piloto , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Factores de Riesgo , Resultado del Tratamiento , Estados UnidosRESUMEN
BACKGROUND: State-based peer review organizations (PROs) and individual hospitals are challenged to achieve their quality improvement (QI) goals with shrinking resources. In 1993-1994 the Connecticut PRO and 15 local hospitals generated a comparative QI database on acute myocardial infarction (AMI) care for 1,202 Medicare and non-Medicare patients discharged in 1992 and 1993. METHODS: A steering committee composed of hospital and PRO representatives was assembled to provide oversight. PRO staff developed a chart abstraction tool and trained hospital abstracters who collected and submitted data to the PRO for comparative analyses. Written feedback was provided to all hospitals and supplemented with onsite presentations when requested. Each hospital prepared a written QI plan based on its unique data profile. RESULTS: Opportunities for improvement were identified at all hospitals. The most commonly targeted areas for improvement included the use of thrombolytics at presentation, aspirin at presentation and at discharge, and beta blockers at discharge. Improvement interventions included staff education sessions, development of AMI critical paths and standing orders, and storage of appropriate medications in emergency departments. Self-report data from the hospitals indicate improvements in care. DISCUSSION: PROs and hospitals can augment their individual QI activities by working together to share data, resources, and lessons learned. Twenty-three hospitals are now collaborating with the Connecticut PRO on a similarly designed QI project aimed at improving the care of patients hospitalized with atrial fibrillation. This project includes a more formal means of communicating QI interventions.
Asunto(s)
Hospitales/normas , Relaciones Interinstitucionales , Infarto del Miocardio/terapia , Organizaciones de Normalización Profesional , Garantía de la Calidad de Atención de Salud , Anciano , Connecticut , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
BACKGROUND: State-based peer review organizations (PROs) and individual hospitals are challenged to achieve their quality improvement (QI) goals with shrinking resources. In 1993-1994 the Connecticut PRO and 15 local hospitals generated a comparative QI database on acute myocardial infarction (AMI) care for 1,202 Medicare and non-Medicare patients discharged in 1992 and 1993. METHODS: A steering committee composed of hospital and PRO representatives was assembled to provide oversight. PRO staff developed a chart abstraction tool and trained hospital abstractors who collected and submitted data to the PRO for comparative analyses. Written feedback was provided to all hospitals and supplemented with onsite presentations when requested. Each hospital prepared a written QI plan based on its unique data profile. RESULTS: Opportunities for improvement were identified at all hospitals. The most commonly targeted areas for improvement included the use of thrombolytics at presentation, aspirin at presentation and at discharge, and beta blockers at discharge. Improvement interventions included staff education sessions, development of AMI critical paths and standing orders, and storage of appropriate medications in emergency departments. Self-report data from the hospitals indicate improvements in care. DISCUSSION: PROs and hospitals can augment their individual QI activities by working together to share data, resources, and lessons learned. Twenty-three hospitals are now collaborating with the Connecticut PRO on a similarly designed QI project aimed at improving the care of patients hospitalized with atrial fibrillation. This project includes a more formal means of communicating QI interventions.
Asunto(s)
Servicio de Cardiología en Hospital/normas , Infarto del Miocardio/terapia , Organizaciones de Normalización Profesional , Terapia Trombolítica/normas , Gestión de la Calidad Total/organización & administración , Anciano , Connecticut , Conducta Cooperativa , Bases de Datos Factuales , Femenino , Humanos , Masculino , Persona de Mediana Edad , Evaluación de Procesos y Resultados en Atención de Salud , Terapia Trombolítica/estadística & datos numéricos , Factores de TiempoRESUMEN
This was an exploratory investigation of psychosocial risk factors for mortality in women with premature acute myocardial infarction (AMI). Subjects were 83 female participants in the Recurrent Coronary Prevention Project, who were between the ages of 30 and 63 in 1978, nonsmoking, nondiabetic, and at least 6 months beyond their index AMI. Follow-up ranged from 8 to 10 years, with an average of 8.5 years. Six deaths occurred in the 83 women over the follow-up. Univariate predictors of these deaths were arrhythmias on ECG (RR = 7.83, p = .003), being divorced (RR = 6.9, p = .003), being employed without a college degree (RR = 6.8, p = .03), and the inverse of Type A behavior, time urgency, and emotional arousability (p = .03; .005; .006, respectively). Multivariate stepwise logistic regression analysis produced a solution that included as independent predictors: arrhythmias on ECG (RR = 4.01, p = .004), being divorced (RR = 3.43, p = .01), and the inverse of time urgency (RR = 0.35, p = .02). In the multivariate model, "divorced" was interchangeable with "employed without a college degree" and "time urgency" was interchangeable with "emotional arousability." This small sample precludes firm conclusions, but provides a basis for hypothesis development.